Quality streetBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7186.758 (Published 20 March 1999) Cite this as: BMJ 1999;318:758
Mark Pownall spoke to Peter Griffiths, director of the Health Quality Service
The UK National Health Service is currently reeling from an unprecedented number of government initiatives which are intended to improve quality and smooth out the largest geographical variations in standards. There are the two new bodies, known by the headline friendly acronyms NICE (the National Institute for Clinical Excellence) and CHImp (Commission for Health Improvement). There is also “clinical governance,” the slippery concept that covers, among other things, clinical audit, promotion of evidence based practice, and the identification and improvement of poor performance.
“The key issue for chief executives, clinical directors, and medical and nursing staff is not health service policies themselves: it is making sense of the new government's ambitions in terms of quality, day to day on the ground,” says Peter Griffiths. Griffiths is now head of the Health Quality Service, an organisation which is attempting to turn the opaque prose of health circulars and policy documents into practical changes to the way doctors and others in the health service organise themselves and their work.
Griffiths has been at the sharp end himself. In 1963, at the age of 18, he joined the NHS in his native Wales straight from school as a junior administrator trainee. In a smooth rise up through the ranks he became deputy chief executive of the NHS, and at different times ran one of London's largest teaching hospitals, Guy's, for three years, as well as two NHS regions, Wessex and the West Midlands.
For Griffiths, methodically reviewing quality is not about squeezing the fuzzy complexities of real life health services into a series of check boxes for the sake of it. He passionately believes that systems, as much as individuals, have fallen short and contributed to the development of scandals like the Bristol paediatric heart surgery cases.
“Being disciplined and organised can be a pain in the arse,” he candidly admits. “But if you are not being disciplined and organised, it does lead to the kind of tragedies we have seen in the NHS recently.
“We need to ask: was there a procedure, was it followed, was routine review built into clinical practices? These kind of system failures have emerged in the findings of many of the inquiries that we have seen.”
In 1994 Griffiths left hands-on NHS management to join the King's Fund, the health policy think tank that has gained respect as an independent source of expertise and ideas regardless of which way the UK's political wind has been blowing. Initially he was director of its management college; he then headed a programme that established standards of organisational audit, which attempted to do for the management of health care what clinical audit was intended to do for clinical services.
The Health Quality Service is a semi-autonomous spin off from the King's Fund. It is a non-profit making charity which has about 25 full time staff and which draws on a pool of 450 senior managers, doctors, and nurses who, says Griffiths “freely give of their time to help our work,” and act as “peer reviewers” of standards of service, looking at parallel services to the ones they manage in their own workplaces.
The inspection of services by peers helps reduce the likelihood of a survey antagonising those whom it is intended to support. “We do not have the ‘battle lines drawn’ approach,” Griffiths comments, “because the people who carry out the surveys are respected colleagues, not an outside inspectorate.”
About a third of NHS trusts now use the Health Quality Service as well as 40%of private hospitals and about 75 primary care groups. With the introduction of clinical governance the service's seal of approval may become more popular as a way of proving organisational fitness to practice.
The senior figures who act as “surveyors” visit health services, including GP practices covering a few thousand patients and health authorities with budgets running into hundreds of millions of pounds, and review the ways in which they are meeting sets of explicit standards. The two to three pages of standards for each area are provided from a bank of standards at the service.
The standards run to hundreds of pages and cover all aspects of health service provision. NHS trusts, for example, are expected to abide by a set of standards that refer to patients' rights. These recognise the right of patients not to take part in undergraduate or clinical staff training and the right to a second opinion.
Some standards impinge more closely on clinical practice. Those that cover accident and emergency services require that medical staffing levels be in line with those recommended by the British Association for Accident and Emergency Medicine and that an accident and emergency consultant should direct services.
Others are seemingly trivial: making sure that appointment letters tell patients where they should attend and what they should bring with them.
The peer reviewers, typically a team of four comprising a chief executive, a clinical director, a director of nursing, and another health professional, survey an organisation over 1-5 days to see how it is meeting standards and report back.
Although few services meet all the standards first time round, most do become fully accredited, a status which lasts for three years subject to annual review. Accreditation is a lengthy procedure—taking a year or more—and involves, Griffiths acknowledges, “a lot of paper.” But those who persevere insist that it is worthwhile, he says.
“The people who go through the process genuinely find it a very disciplined and systematic way of reviewing organisational and clinical practice,” Griffiths says. “It is not seen as a bureaucratic chore.”
To support his argument he points out that a large proportion of those who gain accreditation choose to do it all over again when their three years are up. “Seventy five per cent of those we see have been through the process before, so they must get something out of it.”
Health services, whether publicly or privately funded, cannot expect to be laws unto themselves, Griffiths argues. “It is a very sound principle that all health facilities are subject to some kind of voluntary independent assessment.
“As citizens we would be anxious if there were doctors who were practising who were not properly qualified. It is equally important for the whole hospital or the whole primary care practice to be subject to review.”
“We do not have the ‘battle lines drawn’ approach because the people who carry out the surveys are respected colleagues”